Comparing Apples to Apples in Health Care III

Here are links to the first and second articles in the Apples to Apples series.

FactCheck.org, an institution I greatly support, has gotten into the survival rate issue. Previously I've been criticizing the comparison of health care systems via life expectancy and infant mortality rates while promoting survival rates for specific ailments as a better comparison of systems. FactCheck has taken it upon themselves to criticize straight survival rate numbers.

They start by conceding the obvious difference in the stats: "Across the board, the United States boasts a higher five-year relative survival rate than the European average," they say. "But survival rates also differ within the United States, between insured and uninsured populations. […] survival rates among the uninsured were [&hellip] similar to Europe[.] […] Rates for people on Medicaid were similar to the uninsured."

That initially looks pretty good for the US status quo, but this is a comparison of the USA to Europe, not to socialized medicine. When comparing cancer survival rates from the USA to Canada, Japan, Australia and Cuba (all nations with single-payer government health coverage systems) we come up even or low pretty consistently. (Except with prostate cancer, which is apparently more of a money-maker for doctors than a major harm to public health.)

Also, early detection campaigns can distort a nation's survival rate numbers; catching cancer early rather than waiting for more serious symptoms means you're treating a weaker form of the cancer. Even with identical health care systems, early detection means a better survival rate. Thus, societal differences can distort the comparison of health care systems. Europe isn't big on cancer screenings, and neither are the American uninsured. That explains pretty well why the lower tier of Europe and uninsured Americans doesn't really compare to the higher tier of care enjoyed by socialized medicine and the American insured.

As their dedication to non-partisanship demands, FactCheck.org refuses to take sides on the debate overall. Survival rates do make the USA look much better than life expectancy and infant mortality statistics do -- we have great survival rates overall. Also, it doesn't bode well for the public option when it's current American counterpart, Medicare, is more like being uninsured than well-covered. Thus, these points could be used to argue against the public option before the legislature. On the other hand, insured Americans essentially tie the four socialized medicine nations mentioned suggesting that a socialized medicine system would mean top-tier coverage for all. "There's no way to know!" is the unspoken FactCheck theme.

What would be ideal is a statistical analysis of deeply similar cases in different nations. Great collections of parallel case studies would give a good comparison view of the systems. But I haven't seen any sign that anyone has done that. So the job is to derive what conclusions we can from the information given.

The big thing that strikes me hardest is cancer survival rates: the USA is the worldwide best at surviving breast and prostate cancer ^[source], but FactCheck explains that away as powerful early detection campaigns. Which makes sense. That leaves me without any way to guess which nation has the best cancer treatment.

That leaves the pro-US-system argument heavily relying on a sentence from Wikipedia of all places: "Canadian patients [...] had a 17% higher risk of dying from heart attacks than did U.S. patients." ^[source] Okay, technically it refers to a study in the cardiovascular medicine journal Circulation, but I haven't actually read that article. It's a thin strand to cling to. Maybe, despite my confident facade, I really don't know who has the best health care system.

One of the Wikipedia footnotes links to this article, gives a brief analysis of some of these same points, followed by a great and universal principle that I shall now steal as the beginning this article's conclusion: "The available data often do not provide clear answers." That being the case, isn't a diversity of approaches the best way to determine the best approach? The USA should remain unique until it's system is proven inferior. Since such proof remains elusive, don't fix anything.

Comparing Apples to Apples in Health Care II

My first Apples to Apples post is here.

Often, the health care systems of various nations are compared by infant mortality rates, a scale upon which the United States ranks badly. But the comparison is awash with inconsistencies that distort the national scores based on the national rules of self-assessment. Some examples of regional rules:

• the U.S. tabulates every birth, even in poor, small and remote areas, while other countries are not always so meticulous.
• We also count every baby who shows any sign of life, irrespective of size or weight at birth.
• much of Europe treats babies born before 26 weeks' gestation who later die as miscarriages rather than infant deaths.
• Switzerland only counts babies who are at least 30 centimeters long (11.8 inches) as being born alive, thus disqualifying smaller babies from infant mortality numbers.
• Along the same lines, Canada, Austria and Germany only count babies weighing at least a pound as live births.
• many industrialized nations, such as France, Hong Kong and Japan don't count infant deaths that occur in the 24 hours after birth. About half of infant mortality in the USA takes place in that same one-day period.

Also, ethnicity and lifestyle choices make huge differences in infant mortality. Thus, our national diversity and freedom of choice also work against our infant mortality rate.

Once again, the claims that the American health care system is a national shame are discredited. Remind me, why is it we're so convinced it needs major reforms?

Note: This article was also posted on my new blog site. It's still very rough and incomplete, but it allows users to sign up and leave comments. Unlike this blog, it even has a mechanism to quote from the article and others' comments.

Is the Health Care Overhaul Constitutional?

Even FactCheck.org was unable to answer that question definitively. I obviously oppose the health care reforms being considered.

The FactCheck.org analysis makes both sides of the issue sound pretty rational and reasonable, with one major exception:

Mark Hall, professor of law and public health at Wake Forest University’s law school, writes that there is no fundamental right to be uninsured. "The liberty in question is purely economic and has none of the strong elements of personal or bodily integrity that invoke constitutional protection," he says.

The sentence in bold is terribly ominous. It is horrifying to me that the right to property ("purely economic" liberty) is considered so easily divisible from the right to life ("personal or bodily integrity"). Bodily integrity is protected, day by day, by such material goods as clothes, shelter, seat belts, etc. These things are in turn provided by money, a purely economic entity. The core purpose of money is that we cannot possibly know every material good we may need in the future, so we have a general, all-purpose good that can be exchanged for whatever object fills whatever needs may arise.

Money is material security. Economics is how people attain material security. Purely economic liberty empowers one to protect one's own personal and bodily integrity. To impose upon economics liberties is a little push toward naked, homeless starvation. You cannot separate economic and personal liberties. Like energy and matter, they are phases of the same thing.

How is health insurance more directly related to personal, bodily integrity than cash money? The major difference I see is the difference between cash money and a food stamps or gift cards: one can be used for anything, while the other is limited. Also, food stamps and health insurance cost radically more to oversee and implement, so you get less out of it than you put into it. The generalized, low-cost version works better.

I'm absolutely convinced that forcing people to be consumers to a particular industry is wrong. I'm strongly confident (though not absolutely) it should be unconstitutional, but I'm a little doubtful that it actually will be declared unconstitutional. I far prefer it simply lose out in Congress, preventing it from consideration in the Supreme Court. But maybe I'm wrong. Maybe it'd be better for it to be considered by SCOTUS while it has this kind of chance of being declared unconstitutional rather than in some socialist future where opposition to centralized economic control has collapsed.

Save us from government's good intentions!

Absolute Writer's Block Found Something

Sorry, I've got nothin'. I'll try again tomorrow.
Here's a comment on high-end health plans ("Cadillac health plans"), taxes, and the economy generally. It's pretty interesting.

Obameter #77: Fund Community-Based Prevention

I'm sick of describing health care. My view boils down to a single point: American health care is generally better, if you can get it. Our system specializes on specialization at the expense of universal insurance. So many countries have universal health care, so everyone can get B+ medical care but A+ care remains elusive. We could do the same. But why should we?

Expanded funding for that kind of broad, general care was promised by Barack Obama and $851 million to that effect was announced by Michelle Obama. The Obama Administration is very successfully pursuing the health care reforms he believes in and I oppose.

It has become redundant to say so.

I need a new perspective on the issue. I need to think about it in a new way. To that end, I present a rebuttal to the Green Party's argument in favor of universal health coverage.

1. They argue that the United States is the only industrialized nation that does not consider health care a right. That's true, and logically correct. Rights are things government cannot do to you. Government cannot restrict your associations or self-expression, take your property, punish you without a trial... those are rights. Health care is done for you. It is a service, not a right.
2. They argue that the US health care system is not the best in the world because American health is low. That is because people are not using the system. Individual patients of the American health care system achieve better health than patients of other health care systems. By that measure, the American system is the best health care system in the world.
3. American health care is more expensive than that elsewhere in the world. Of course it is. Most health care elsewhere is general care. Most health care in the USA is specialist care. Specialist care is more expensive than general care. It's also more effective.
4. The American system denies people service based on their ability to pay. Universal health care denies people services based on limited availability of specialist services. We have the "oversupply" of equipment stated because of the redundancies of competitive industry. If you remove that cause, we will face the same limited supply of specialist services that other nations face.
5. They argue that no laws, rules, or regulations would limit choice of health care provider under a universal care system. This is true. Scarcity, not rules, would dictate availability. The rest of their arguments in this section are against corporate restrictions on health care, which I oppose just as much as I oppose government restrictions on health insurance. You get more choice when you pay for it yourself.
6. They argue that universal health care is not "socialized medicine" because the government is only paying for the health care, not providing it. This is true. It's socialized medical insurance. They also mention that approximately 2/3rds of people support universal coverage. Speaking of rights, why force a system onto the other third that they don't want? Individual states can already provide universal medical coverage at the state level, leaving people the choice of whether to pay for it by choosing what state they live in.
7. In arguing that the American system is not being reformed, they compare for-profit and not-for-profit medical care prices. What does that have to do with government handling of payments? Apart from that, this just repeats the third point about costs: American health care is more expensive and more effective at the cost of availability.
8. They blame corporate lobbies for health care not passing. Why would corporations oppose it generally? It transfers the costs of health insurance from them to government. Medical corporations lobby against universal care to save themselves. They also fund most of the world's medical technology research and development. Maybe it's a good thing they exist.

That didn't really help. It seems identical to the other arguments I've heard. They're still arguing that decreasing prices at the cost of specialization is a good trade.

The way in which this is socialism is that it cuts off the peaks of the mountains to raise lower elevations. It raises the worse case by sacrificing the best case. The American spirit is an aspiration to achieve the best case - or, preferably, to create an even better best case. To remove the best possible outcome from possibility is unAmerican. That is why we are the only industrialized nation without universal health care. We associate ourselves with the best possible outcome. Thus, eliminate the best possible outcome is to hurt ourselves.

Comparing Apples to Apples in Health Care

In the modern health care debate, it is extremely tempting to compare the American system as it exists now to foreign systems that resemble to degrees the universal health care system currently before the American legislature. It's quite a rational way to estimate the influence this new legislation would have if passed.

The most common comparison along these lines is life expectancy. That comparison is not rational at all. Medical care availability, it's effectiveness, and that of medical insurance affects life expectancy in ways deeply clouded by causes of death that cannot possibly be altered by medical attention. Americans drive more and further than citizens of other nations, increasing our vehicular accidents and, thus, on-the-scene deaths from that cause. We have radically more firearm deaths to the same effect. We are culturally more likely to try to personally, physically stop violent crime or armed robbery, which again decreases our life expectancy in ways unrelated to medical insurance, care, and science.

How do we measure up on direct comparisons of specific causes of death? That is a far better comparison of effectiveness of medical care. Of 100 patients for a given disease, what percentage are alive one year, five years, ten years later? That is a level scale.

So how do we compare? There are thousands of causes of death that could potentially be covered, and information for uncommon approach is less readily available. The full answer is beyond the scope of a blog post and of my own capability as a researcher. But I'll address what few examples I have found.

Of 31 countries statistically analyzed by one recent CDC-funded study (as reported by WebMD, for those without subscriptions to medical research websites), the U.S. has the highest 5-year survival rate for breast and prostate cancer. France and Japan beat us out for the other two cancer types covered, colon and rectal cancers.

If this factor alone were all to consider, it would put the USA tied or ahead of both France and Japan. World Health Organization declared France to have the best health care system in the world ^[source]. By the same WHO source, Japan ranked 6th and the USA ranked 37th. Already, conflict arises. According to Wikipedia, "The WHO [...] placed heavy emphasis on the health disparities between rich and poor, funding for the health care needs of the poor, and the extent to which a country was reaching the potential health care outcomes they believed were possible for that nation." ^[source] Thus, theirs is more a measure of whether health care is universal than whether it is effective.

The USA also leads the world in gunshot wound survival rates. With all our extra practice, does anyone doubt that claim? The effect on life expectancy would be neutralized by our far greater frequency of occurrence of gunshot wounds, yet it testifies of the effectiveness of our medical capability.

According to Wikipedia's coverage of a international cardiac study, "Canadian patients [...] had a 17% higher risk of dying from heart attacks than did U.S. patients." It is further suggested that that the American culture of cardiac treatment is more effective at saving heart attack victims' lives because of "the greater use of invasive procedures in the U.S." and that "specialized procedures are only available in central hospitals" in Canada but are more abundant in the USA. This suggests that more advanced care is less available under a universal health care system, and that the difference is responsible for a significant number of people's lives. ^[source]

(If I have not said so previously, let me say so now: I don't believe universal health care creates "death panels" who decide whether you live or die, but rather that financial realities will create shortages of certain advanced and expensive care options. Previously I considered some hospital accountant encouraging against certain procedures, but after reading the previous example my views are altered to say "Exactly like that.")

Of course, two three examples are insufficient to prove anything. My argument is limited by the comparative difficulty of coming up with comparisons of various nations by cause of death. But the approach is better logic and, so far, seemingly puts the existing US heath care system in a far better light. How sure are we that our health care system is so horribly behind the other industrialized nations of the world?

If we can't be sure it's broken, why are we striving to fix it?

Updated at 11:45 am on 24 Sept 2009.

Obameter #58: Expand SCHIP

After the failure of the Clinton health care plan of 1993, First Lady Hillary Clinton was looking for a smaller health care plan that would be more acceptable to Republicans and, thus, could potentially be passed into law. Specifically, she wanted a program to insure children whose families were only barely ineligible for Medicare. At the same time, Senator Ted Kennedy (D-MA) was looking to expand his home state's children's health care plan to a national scale, paying for it with an increase in cigarette taxes. Having convinced his friend from the other side of the aisle, Orrin Hatch (R-UT), to co-sponsor the bill (something which conservatives nationally wouldn't forgive him for until his adamant defense of Supreme Court Nominee John Roberts in 2005).

One criticism of the bill at the time was that such a steep cigarette tax increase (from 23¢ per pack to 67¢) would reduce sales to the point where no revenue would actually be produced to offset the $24 billion cost of the bill. Orrin Hatch responded, "If we can keep people healthy and stop them from dying, I think most Americans would say 'Amen; isn't that a great result?' If fewer people smoke, states will save far more in lower health costs than they will lose in revenues from the cigarette tax." Then Senate Majority Leader Trent Lott (R-MS) argued against it, calling it a "big government program" and claiming it did not qualify under the Balanced Budget agreement between the Senate and the White House. Then-President Bill Clinton, who was responsible for compliance to the balanced budget agreement, called up many Senators to personally dissuade them from voting for the bill. On May 22nd, the bill failed in a vote of 55 to 45.

Senator Kennedy considered it a personal betrayal by a White House that cared more about the tobacco lobby than children's health. He and Hatch proposed the bill again a month later, this time as an amendment to the Balanced Budget Act of 1997 and with Hillary Clinton advocating for it in the White House. This time it passed. It passed in the House of Representatives easily, along party lines, and with relatively little drama.

The program was named "the State Children's Health Insurance Program" (abbreviated SCHIP or sometimes CHIP), and works by giving federal funds and a loose template for regulation of the program to states, who then apply the money to health insurance for children who might otherwise be uninsured or underinsured. Though originally aimed at children in families who were had only barely enough income to disqualify them for Medicare, some states have been given exceptions allowing dual coverage by Medicare and SCHIP.

Researchers from Brigham Young University (from Orrin Hatch's home state) and Aizona State University found that children removed from SCHIP tended to cost their states more money due to their care taking place as expensive emergency care rather than relatively cheap preventative care. Researchers from the Congressional Budget Office and the libertarian Cato Institute show that approximately half of children covered by SCHIP moved there from private insurance coverage -- in other words, that the program is "crowding out" private insurance coverage as much as it is covering the uninsured. Also, the expected ten-year cost of $24 billion ballooned to an actual cost of $40 billion.

After the 2006 election, the Democrats jumped to a near-2/3rds majority in both the House and Senate, just shy of what is necessary to override a Presidential Veto. Given their new-found influence, they sought to expand and extend the SCHIP program. In the Senate, they passed a bill intended to increase the planned $25 billion 5-year cost to $60 billion and loosen the federal restrictions on State implementation of the program. In the House they also voted to extend $6.5 billion in Medicare coverage to illegal immigrants. George W. Bush vetoed this SCHIP expansion, saying he opposed centralized, "federalized health care" on principle. Though some Republicans voted to override the President's veto, the overall vote was 13 votes shy and the veto was final.

Within a week, Democrats proposed the plan again, claiming they had improved the restrictions to keep the wealthy and non-citizens from gaining coverage. Bush vetoed it again, and the attempt to override his veto again failed.

By December 21, 2007 the Democrats had managed to find a sufficiently weakened extension of SCHIP that President Bush was willing to sign it into law. Rather than five years of an expanded program, it simply extended the existing plan until March of 2009. Essentially, it was an agreement to put off the question of SCHIP expansion until after the next election.

After Obama's election and the Democrat legislative gains of 2008, the issue was brought up once again. This time, the Democrats proposed to spend $32.8 billion (rather than $35 billion) and raise taxes on a variety of tobacco products to pay for it. 4 million more children are expected to be covered than under the old plan

The drama of the story is more interesting to me than the pros and cons of the policy itself, especially early on when it pitted Orrin Hatch against Trent Lott and Ted Kennedy against Bill Clinton. That was high drama, and I always favor the dissolution of party loyalty in favor of personal ideology. But the policy falls back on the usual, boring issues of government health insurance, "sin taxes", and Washington's complete disregard for budget balancing in name or spirit.

Each individual point is easy. I support healthy children. I oppose government insurance plans. I prefer state implementation over centralized, national programs. I oppose sin taxes, but not so much as I oppose most other forms of taxation. And the lack of balanced budgeting in Washington is the biggest, most publicly harmful disgrace in politics today.

Beyond all that, my greatest criticism is the great casino of health insurance. Public option, private option, however you slice it the design of health insurance is inherently a scam, a black hole which sucks away money from everyone.

Okay, I need to back up. That's a hugely controversial claim that needs better explication than that.

In a world without health insurance of any kind, a person like me would either save money or not and, in a medical emergency, would either be able to pay or not. Thus they would either live or not. It's a harsh world. People live or die based on how much money they have, or how much they can borrow or beg from banks, friends, and family. It's not a world I especially like.

The basis of medical insurance comes from people seeing the harshness of this world and seeking relief from it. Thus, they set up small, local groups dedicated to taking small, voluntary donations from many people to create a fund from which they can pay for emergency medical care. Ten people each give $10 a month to a central fund so that, on their 5th anniversary, they can pay $60,000 for heart bypass surgery for one of them. Ten people just paid for one person's life. That's fine, they're all friends and they feel heroic to be able to save their friend. It's a good thing for everyone.

It works so well, in fact, that big thinkers decide to do the same thing on a bigger scale. They establish charities, corporations, or government programs to provide such peace of mind to a great many people.

Voluntary donations to charities work great - people expect their money to help the unhealthy, and don't much care whether they personally benefit or not. They likely won't personally witness the results of their donations and, thus, won't be as willing to donate. But it works. It's worst fault is a tendency toward the impersonal, including the possibility that your money will go to help someone you wouldn't personally approve of helping. But that's pretty minor, espeically when compared the next few options.

Payments to Insurance Corporations are expected to pay for themselves, which pits customer and provider inherently against each other in a zero-sum game: either the company survives because the customers lose money, or the company goes bankrupt. Any insurance company that still exists gets more than it loses and, thus, it's customers lose more than they get. If that means they charge too much, or reject claims they should approve, or whatever means it takes the company will try to be profitable which is necessarily at the customers' expense. It's Las Vegas Insurance: the house always wins. But who knows? Maybe the peace of mind is worth more money than the customer loses. Maybe, for people besides me, especially people with worse than average health, maybe it's a worthwhile thing. Of course it's good for the big lotto winners who get their cancer care or open heart surgery paid for. But just like Vegas, the system only works when winners are an extreme minority.

Then comes the government option. In true socialized medicine is where everyone pays to one big pot and the pot pays for everyone's insurance. If you're healthy, you don't know who is benefiting from the money you pay in. If you're sick, you don't know who's saving you. And if you're too sick and the government bureaucracy sentences you to die because the cost/benefit ratio of saving you is just too high. It's just as harsh as the insurance-free world, but without any element of self-determination.

And lastly, the public option. The great government opt-in plan, paid by everyone for a select, needy few. The few certainly win - the get more health care paid for them than they can otherwise afford. But the many are paying for medical care twice - once for the public option of the few, and again for their own care. Thus, there is always a financial incentive to join the few. Either a line is drawn saying "This is all those who qualify," or the many continue to join the few until there is no one left to pay for the program. Covering more people inherently means more weight on the many or fewer benefits for the few. And that is exactly what Obama's SCHIP promise was to do: cover more children.

4 million children will step up from the lowest medical care demographic in the country to the SCHIP level, which is quite good. And the rest of the country will fall a tiny, imperceptible bit to pay for it. Does that improve the average? It doesn't improve my life, I know that. It doesn't improve my infant nephew's life; he doesn't qualify for SCHIP. All my family and friends will be hurt a teeny, tiny bit. But I shouldn't care. It's for the children, right? A small subset of the children are worth a broad, shallow layer of financial suffering over the rest of us. It's not so bad.

The reasoning of in the previous paragraph is what will continue to strain the economy of this country until it fails. Every new program is not too bad until the sum of them is beyond endurance. Or maybe it'll never go that far. Maybe it'll just be a constant annoyance in the lives of hundreds of millions, an inconvenience they ignore and endure forever for political correctness' sake. I still don't want it. It's still wrong.

Quick Point on ObamaCare

Analysis from the source.

Update: The high-resolution image seems to have been taken down.

"House" and the Public Option

The best TV show around, in my humble opinion, is Fox's "House M.D." I've been watching it since the first episode, I own four seasons of it on DVD (I've seen them all at least 5 times each), and I frequently visit a blog in which an actual medical doctor reviews the show for medical inaccuracies.

That self-same doctor was interviewed by MSNBC for an article about "House" published today. People with real health problems are searching the world for a "real Dr. House", someone who can solve their puzzle and tell them what they have sometime faster than the average of 7 years it takes for a definitive diagnosis for a rare disease.

The article ends with a criticism against the TV doctor that the TV show itself has already addressed. From the article: "In med school, doctors-to-be learn the opposite, summed up by the adage, 'If you hear hoofbeats, think horses, not zebras.'" From the show: "Are you in first year medical school? If she had [a common, 'horse' of a disease] the kindly family doctor in Trenton would have made the diagnosis. It'd never get anywhere near this office." Dr. House isn't a fictional version of your family doctor. He's a fictional version of a job that doesn't exist -- the authority that doctors refer you to as an admission that they can't solve your problem. If a regular doctor is your county judge, Dr. House is the Supreme Court. When he has to deal with patients directly in the clinic, he tells them exactly what your doctor will tell you when you talk to them: it's a cold. It's the flu. It's a horse, not a zebra. It's only once the horses are ruled out that Dr. House even comes into play.

One particular story of a too-long-awaited diagnosis struck a nerve.

It took five months — and visits to 21 doctors — before one finally correctly diagnosed her with Lyme disease, a bacterial infection often spread by deer ticks.

That final doctor, she says, did something that all those before her hadn't. “She listened to me,” said Risley, who opted to see a physician who was generous with her time, and got paid well for it, accepting only out-of-pocket payments.

Did you get chills, too? If not, let me spell it out: No one was able to solve her medical problem until she got to the doctor that doesn't accept health insurance. That's not from House, the fictional TV show. No one would write anything so crazily unbelievable. No, no, that's the real-world true story. The elitist, overpaid doctor could afford the time to properly consider and finally solve the puzzle. That's exactly the kind of thing the big Obama Health Bill currently being debated in the legislature is designed to stall. In all our worries about health care costs, we forget one thing: you get what you pay for.

For a further example of the political angle of it, look at Medicare. The principle behind Medicare is that government pays for the health care of the needy. In practice, though, Medicare rarely covers the full price of the service. Doctors have to cut costs, raise prices, and rush through as many patients per day as possible in order to make ends meet when accepting Medicare patients. In short, government health insurance makes health care worse. The White House has been promoting Obama's health care plan with the very words "Medicare for everyone." This spells doom.

You want better medical care? Look to your pocket book. Unlike government programs, it might help.